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Inter Regional General Surgery Meeting April 11, 2010 Surgical Site Infection Prevention Bundle and Plus Measures. Steve Parodi, MD, Chair KP NCal Regional Infectious Disease Chiefs, Chief ID Vallejo, CA stephen.m.parodi@kp.org

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slide1

Inter Regional General Surgery Meeting April 11, 2010Surgical Site Infection Prevention Bundle and Plus Measures

Steve Parodi, MD, Chair KP NCal Regional Infectious Disease Chiefs, Chief ID Vallejo, CA stephen.m.parodi@kp.org

Sue Barnes, RN, CIC, National Leader, KP Infection Prevention and Control - National Office - Oakland, CA sue.barnes@kp.org

overview
Overview
  • Bundle vs. Plus Measures and supporting evidence
  • Success stories for top 3 Plus Measures
  • Definitions, detection and reporting (including NSQIP vs. NHSN definitions)
  • Public reporting mandates by region
  • PAB guidelines supporting infection prevention
bundle measures vs plus measures
Bundle Measures vs. Plus Measures

The Care Bundle concept created in 2002 by VA/IHI when vent bundle was developed

Per IHI definition a bundle = 3-5 practices designed to be performed all at once every time – each is based on RCTs

Plus Measures = prevention efforts supported by less than category 1 level evidence – see KP Plus Measures Toolkit (pg 7-9): http://kpnet.kp.org/qrrm/patient/infection/hot_topics/hot_topics.html

success stories for top 3 plus measures
Success stories for top 3 Plus Measures

Chlorhexidine impregnated bathing cloths or showers pre-operatively

Normothermia

Dual agent skin prep – i.e. Chloraprep or Duraprep

plus measures ssi prevention in addition to scip measures
Plus measures – SSI Prevention (in addition to SCIP measures)

ensure for ortho cases that pre op antibiotic is infused 20 minutes prior to tourniquet application.

3rd party observation of surgical cases using standard IC checklist

cover staff hair (beard, chest, head); clip patient hair (and remove clipped hair) before entering OR; teach female patients no leg shaving for pre op total knee replacement

pre op antiseptic bathing – impregnated cloths vs. shower

post op antiseptic dressings

consider: 3 gms ancef pre op as standard at least for bariatric

decolonization MRSA pre op high risk procedures

antiseptic impregnated post op dressings

revisiting the preadmission preoperative shower
Revisiting the Preadmission (Preoperative) Shower
  • Cochrane Collaborative
    • Eyers PS, et al. Cochrane Database 2006;3: CD003073
    • Edwards et al.. Cochrane Database 2006;3: CD003949. pub 2
  • Conclusion: No evidence-based benefit
  • 6 sentinel studies – legitimate concerns
    • No routine standard of practice
    • Some individuals showered once, other multiple times
    • Heterogeneous study population
    • No evidence of patient compliance
slide7

Pilot Data – Skin Concentration of 4% Chlorhexidine Gluconate (CHG) Following Shower - “Evening” and “Morning” (N = 10)

CHG Shower

“Evening” Group (PM)”

“Morning” Group (AM)”

CHG Concentration (PPM)

MIC90 = 4.8 ppm

Left Elbow

Right

Elbow

Abdominal

Left Knee

Right Knee

Skin Sites

Note: 3 subject in “Evening” and 2 subjects in “Morning” groups recorded no CHG concentration at 1 or more skin sites

slide8

4% Chlorhexidine Gluconate (CHG) Shower -

Skin Surface Concentration (N=60)

CHG Shower

Group 1A “Evening (PM)”

Group 2A “Morning (AM)”

Group 3A

“Both (AM and PM)”

CHG Concentration (PPM)

p <0.05

NS

P<0.001

MIC90 = 4.8 ppm

Left Elbow

Right Elbow

Abdominal

Left Knee

Right Knee

Skin Sites

Edmiston et al, J Am Coll Surg 2008;207:233-239

slide9

2% Chlorhexidine Gluconate (CHG) Impregnated Cloth Application – Skin Surface Concentration (N = 60)

CHG Cloth Application

Group 1B “Evening (PM)”

Group 2B “Morning (AM)”

Group 3B

“Both (AM and PM)”

CHG Concentration (PPM)

p<0.05

p <0.001

MIC90 = 4.8 ppm

Left Elbow

Right Elbow

Abdominal

Left

Knee

Right Knee

Skin Sites

Edmiston et al, J Am Coll Surg 2008;207:233-239

efficacy of preoperative chg wipes
Efficacy of Preoperative CHG Wipes
  • Observational non-randomized use of 2% CHG impregnated cloths on orthopedic total joint patients - SSI Rates dropped 50.1% (3.2% to 1.6%)
  • Need randomized studies
  • Need to make sure patients adhere to protocol for application

Eiselt, Ortho Nurs 2009;28:141-5

slide11

A PROSPECTIVE, RANDOMIZED, MULTICENTER CLINICAL TRIAL OF 2% CHLORHEXIDINE GLUCONATE / 70% ISOPROPYL ALCOHOL (Alc-CHG) VS POVIDONE-IODINE (PI) FOR PREVENTION OF SSI

  • Patients > 18 years, undergoing clean/clean-contaminated procedures (gastrointestinal, thoracic, urologic and gynecologic)
  • N = 820 surgical patients: 400 Alc-CHG vs. 420 PI :1 randomization
  • Patients monitored for 30 days post-op
  • Overall rate of SSI was significantly reduced in Alc-CHG vs. PI groups: 9.8 vs. 16.9, p<0.003
  • Significant difference (p<0.01) in superficial incisional site rate: 4.3% (A-CHG) v. 8.6% (PI) – rate for deep incisional 1% v. 3%
  • No significant difference for organ space infection
  • No significant adverse events noted during the study in either group
  • Alc-CHG superior to PI in reducing the risk of SSI in clean/clean-contaminated procedures

Dairouche, NEJM 2010;362:18-26

what to do about mrsa
What to do about MRSA?

Conflicting Studies Regarding Preop Screening

  • Large randomized crossover trial using universal screening of specialty v. general surgical patients for MRSA. MRSA patients received decolonization and periop vanco. No difference in SSI rates.
  • Smaller controlled trial screened patients, treated with decolonization and daily CHG baths. Excluded “simple procedures.” Reduced S. aureus SSI rates by 60%.

Screening generally restricted to more complex procedures (i.e. implants, CV surgery)

Harbath JAMA 2008;299:1149

Bode NEJM 2010;362:9

slide13

Perioperative Antimicrobial Prophylaxis in Higher BMI (>40) Patients: Do We Achieve Therapeutic Levels?

Percent Serum/Tissue Concentrations Achieving Therapeutic levels at a 2 gm (N = 38) and 3 gm (N = 40) Perioperative Dosing Regimen

2-gma 3-gmb

Organism N Serum Tissue N Serum Tissue

S. aureus 70 68.6% 27.1% 92 87.5% 68.5%

S. epidermidis 110 34.5% 10.9% 156 64.5% 49.6%

E. coli 85 75.3% 56.4% 101 92.4% 86.5%

Kl. pneumoniae 55 80%65.4% 49 96.8% 90.4%

a period covering 2001-2003

b period covering 2006-2008

aEdmiston et al, Surgery 2004;136:738-747

bEdmiston et al., Submitted for publication 2009

slide14

Evaluation of Antiseptic Activity of Triclosan-Coated Polyglactin 910 Suture at 24, 48, 72 and 96 Hours Compared to Standard Polyglactin 910 Braided Suture

Non-coated polyglactin 910

p<0.01

24 hr VT

48 hr VT

72 hr VT

p<0.01

Mean colony forming units (cfu)/cm suture

96 hr VT

N=10

NS

NS

S. aureus (105)

MRSA

S. epidermidis (105)RP62A

Edmiston et al, J Am Coll Surg 2006;203:481-489

slide15
Antimicrobial Suture (AMS) Wound Closure for

Cerebrospinal Fluid Shunt Surgery: A

Prospective, Double-blinded, Randomized

Controlled Trial

  • The shunt infection rate in the study group was 4.3%, while the
  • infection rate was 21% in the control group (p = 0.038). There were
  • no statistically significant differences in shunt infection risk factors
  • between the groups. These results support the suggestion that the
  • use of AMS for CSF shunt surgery wound closure is safe, effective,
  • and associated with a reduced risk of postoperative shunt infection.
  • Rozzelle et al., J Neurosurgery 2008;2:111-117
definitions nsqip vs nhsn
Definitions: NSQIP vs. NHSN
  • NSQIP Definition:
  • Identifies by CPT code
  • reports SSI data in 3 procedure categories combining various procedures: general, vascular, colorectal
  • uses O/E (observed/expected) ratios instead of infections/procedures x 100 (rate) instead of infection rates
  • NHSN Definition:
  • categorized by wound severity: superficial, deep, or organ space
  • all surgical procedures reported separately
  • rates are stratified by risk index 0 – 3: one point assigned for each of the following:

1. Operation lasts for longer than 2 hrs

2. Contaminated or dirty/infected wound classification

3. ASA Classification of 3, 4 or 5.

public reporting mandates by region
Public reporting mandates by region
  • NWICU BSI, SSIs total knee and CABG
  • COBSI in ICU, VAP, SSI in THA, TKA, Hernia, CABG, and Vag hyst.
  • HAWAIIno reporting required
  • MASMD - BSI in the ICU, SSI CABG, hips and knees; VA - BSI; DC -MRSA, SCIP measures
  • GAno reporting at this time
  • OHno reporting at this time
  • NCAL/SCALMRSA Bloodstream Infections (BSIs), Clostridium difficile infections, VRE BSIs, Non-ICU Central line-associated BSIs not reported through NHSN, Deep or organ/space Surgical Site Infections not reported through NHSN, Orthopedic (total knee/hip), Cardiac (CABG), GI (colon resection), SCIP
pab guidelines supporting infection prevention
PAB guidelines supporting infection prevention

Infusion of the first antimicrobial dose should begin within 60 minutes before the surgical incision

Infusion antibiotic completed 20 minutes prior to inflation of tourniquet for total knee

Discontinue 24 hours post operatively

Adjust dose by weight

Order set